Pramipexole to Clonazepam

[KeithWilliams]

I’m currently on 0.54mg of Pramipexole supplemented by 30mg Codeine each day. It has been suggested that I should switch to Clonazepam. Any views on this possible switch and how the conversion should be managed.

[SueJohnson]

Welcome to the forum. You will find lots of help, support and understanding here.

You definitely should get off the pramipexole as it can lead to augmentation but you don't want clonazepam. It is basically a sleeping pill and with a long half life of 40 hours will make you sleepy the next day, At one time it was thought to help RLS but it doesn't.

First off check if you are on the slow release pramipexole. The slow release ones usually have ER or XL after their name. If so you need to switch to the regular pramipexole because the slow releases ones can't be cut.

To come off pramipexole reduce by half of a .088 [.125] tablet) (ask for a prescription of these if needed) every 2 weeks or so. You will have increased symptoms. You may need to reduce more slowly or with a smaller amount or you may be able to reduce more quickly. Wait until the increased symptoms from each reduction has settled before going to the next one. You will suffer and may need a low dose opioid temporarily to help out with the symptoms especially as you near the end. Some have used kratom or cannabis temporarily to help. But in the long run, you will be glad you came off it.

Dopamine agonists like ropinirole and pramipexole and the Neupro patch (Rotigotine) are no longer the first line treatment for RLS. Gabapentin or pregabalin are. (Pregabalin is more expensive than gabapentin in the US.) Also don't let your doctor switch you to Neupro (rotigotine). S/he may tell you that it is less likely to lead to augmentation but that has been disproved.

The beginning dose is usually 300 mg gabapentin (75 mg pregabalin) [If you are over 65 and susceptible to falls beginning dose is 100 mg (50 mg pregabalin.)] Start it 3 weeks before you are off pramipexole although it won't be fully effective until you are off it for several weeks. After that increase it by 100 mg (25 mg pregabalin) every couple of days until you find the dose that works for you. Take it 1-2 hours before bedtime as the peak plasma level is 2 hours. If you need more than 600 mg take the extra 4 hours before bedtime as it is not as well absorbed above 600 mg. If you need more than 1200 mg, take the extra 6 hours before bedtime. (You don't need to split the doses with pregabalin) Most of the side effects will disappear after a few weeks and the few that don't will usually lessen. Those that remain are usually worth it for the elimination of the RLS symptoms.

If you take magnesium even in a multivitamin or magnesium-rich foods, take it at least 3 hours before or after taking gabapentin (it is OK with pregabalin) as it will interfere with the absorption of gabapentin and if you take calcium don't take it nor calcium-rich foods within 2 hours for the same reason (not sure about pregabalin). According to the Mayo Clinic Updated Algorithm on RLS: "Most RLS patients require 1200 to 1800 mg of gabapentin (200 to 300 mg pregabalin)."

Have you had your ferritin checked? If so what was it? This is the first thing that should be done for RLS. Improving your ferritin to 100 or more helps 60% of people with RLS and in some cases completely eliminates their symptoms. If not ask your doctor for a full iron panel. Stop taking any iron supplements including in a multivitamin 48 hours before the test, don't eat a heavy meat meal the night before and fast after midnight. Have your test in the morning before 9 am if possible. When you get the results, ask for your ferritin and transferrin saturation (TSAT) numbers. If your ferritin is less than 100 or your transferrin saturation is less than 20% ask for an iron infusion to quickly bring it up as this will help your withdrawal. If you can't get an infusion, let us know and we can advise you further.

Check out the Mayo Clinic Updated Algorithm on RLS which will tell you everything you want to know including about its treatment and refer your doctor to it if needed as many doctors do not know much about RLS or are not up-to-date on it as yours obviously isn't or s/he would never have prescribed a dopamine agonist at Some things that can make RLS symptoms worse for some people are alcohol, nicotine, caffeine, sugar, artificial sweeteners, carbs, foods high in sodium, foods that cause inflammation, foods high in glutamate, ice cream, eating late at night, oestrogen (estrogen) including HRT, dehydration, electrolyte imbalance, melatonin, Monosodium Glutamate (MSG), collagen supplements, eating late at night, stress and vigorous exercise.

Some things that help some people include caffeine, moderate exercise, weighted blankets, compression socks, elastic bandages, masturbation, magnesium glycinate, fennell, low oxalate diet, a low-inflammatory diet, selenium, 5 minute shower alternating 20 seconds cold water with 10 seconds hot water finishing with hot water for another couple of minutes, hot baths, distractions, applying a topical magnesium lotion or spray, doing a magnesium salts soak (epsom salts), vitamins B1, B3, B6, B12, D3, K2, if deficient, and potassium and copper if deficient, massage including using a massage gun, vibration devices like therapulse, using a standing desk, playing and listening to music, creative hobbies, meditation and yoga.

Many medicines and OTC supplements can make RLS worse. If you are taking any I may be able to provide a safe alternative.Https://mayoclinicproceedings.org/a...

By the way it would really help us to give you advice if you would indicate on your profile what country you live in and your gender.

[KeithWilliams in reply to SueJohnson]

Many thanks for your comments. Having had RLS for over 30 years, I have probably tried everything you have listed and more besides! For a long time, Pramipexole was highly effective and I have a conversion programme already in place to move across eith Gabapentin or pregabalin. However, Clonazepam has been a late entrant as it seems to be highly effective for some people but I appreciate that in some other cases, excess sedation is an issue. Thanks again.

[SueJohnson in reply to KeithWilliams]

It are not highly effective and it is an old entry.

According to NightWalkers Fall 2021, which is the monthly magazine of the Restless Legs Foundation "the efficiency has not been established and clonazepam should not be used to treat RLS symptoms"

Also according to the Mayo Updated Algorithm on Restless Legs which is the bible for treatment "There are no adequate controlled trials of benzodiazepines for RLS, and it is likely that the drugs act by treating the associated insomnia or concurrent anxiety rather than the sensory or motor symptoms of the disorder."

Taking clonazepam and gabapentin or pregabalin together is generally not recommended without close medical supervision. Both medications can cause drowsiness, dizziness, and confusion, and combining them can increase these side effects.

You can of course try it. Do be aware it can be addictive and you will need to wean off it very slowly.

[4Curiousosity in reply to SueJohnson]

clonazepam was zero help for my RLS

[Joolsg]

Welcome Keith. Can you tell us where you live? England, USA? Also list all the medications you're currently taking. And ask for full panel iron blood tests.As SueJohnson advises, Pramipexole is no longer used by experts because of inevitable drug-induced worsening (augmentation) and very high rates of Impulse Control Disorder.

RLS-UK has a withdrawal schedule under 'Useful resources' and an iron therapy page.

Clonazepam is not the usual replacement medication after dopamine agonists. It tends not to work very well and causes excessive daytime sedation. So discuss replacement meds again with your doctor and ask them to read the Mayo Algorithm or the NHS cks guidance. Gabapentin and pregabalin are the usual replacement meds.

[KeithWilliams in reply to Joolsg]

Hi, Thanks for your comments. I’ve had all the tests done and well aware of the issues surrounding Pramipexole. Gabapentin is already on my radar . However, in severe cases of RLS, I have heard that Clonazepam was recently identified as a possible replacement. I do understand that in same cases, there has been some excessive daytime sedation which is clearly a concern. Thanks again for your input. Incidentally, I am based in the UK.

[Joolsg in reply to KeithWilliams]

Interestingly, I've just received the new book on RLS by Dr Andrew Spector. The chapter on benzodiazapines confirms there has been very little research on clonazepam for RLS. It confirms that the lack of data supporting the use of clonazepam has pushed it (& other benzos) down the treatment list.

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[KeithWilliams in reply to Joolsg]

Many thanks.

[Alc71 in reply to KeithWilliams]

Hi KeithWilliams I'm also in UK. I too have tried pretty much everything under the sun. I found gabapentin and pregabalin really effective, however they really effected my bladder. I'm currently taking Zamadol 150mg which is a slow release tramadol. The regular tramadol was no way near as effective. It was recommended to me by a fellow sufferer and has been highly effective for me too. Hope you find some relief soon.

[SueJohnson]

In focusing on the pramipexole I overlooked that you are taking codeine. That should help you get off the pramipexole. 30 mg is a low dose and as you get near the end you may want to ask your doctor if you can increase it temporarily as it is the last doses that will be the hardest.

Do note that the gabapentin or the pregabalin won't help much until you are off pramipexole for several weeks and your symptoms have settled.

[amrob123]

Clonazepam is helpful for Periodic Limb Movement Disorder but may or may not be effective for RLS (see other replies). I have taken a low dose of clonazepam on top of pregabalin for several years. While i feel refreshed on it, I do find that clonazepam has an overly sedating daytime effect, even at a very low dose (i take 0.125 to 0.25mg).

[pianoplayerPLMD in reply to amrob123]

I have had RLS and PLMS for 5 years and tried everything, with nothing working. I'm under Dr. Thomas at Spire Clinic and he prescribed Clonazepam saying it "consolidated sleep". I have found it has done just that, my disruptions in the night are very much reduced, and I just sleep massively better, even though I still have restless legs. I'm a bit wobbly when I get up, but a walking stick works wonders. I am very glad I'm on it.

[daisydaisy26]

Just want to share my mother's experience, she was prescribed Clonazepam as some sort of emergency medicine, while she was both on Pramipexole and Gabapentin, and it did help occasionally, but in about a year it stopped working. But I think every case is different, she did not experience any particular dizziness or sleepiness after taking it (I think, she took the minimal dose, 1/4 of a 2.5 mg tablet).

[Carpetbagger]

I had been taking clonazepam for 30 years and it was amazing and totally controlled my restless legs apart from when I had the odd serious attack. I agree with the comment by amrob123 that it has a sedating effect but I didn't find that during the day, only had a very good night's sleep (although since coming off it my husband said I was much more alert during the day!). When I was in hospital in June for a hip op the consultant immediately took me off clonazepam saying it was not a drug used these days for RLS due to long term effects and did seem to cause falls (? ) due to dizziness etc. Since coming off it and going on pramipexole things have never been the same. Thanks to this forum for all the information given about dopamine agonists and their dangers. I am only still on pramipexole because the doctors refuse to prescribe me anything else.

[restlessstoz]

My caution with clonazepam is that it caused depression for me and as I have a natural inclination toward depression, I left it behind very quickly. It didn't do much for my legs either so the down side wasn't even worth it!

[art37]

It made me sleepwalk at night and I had a bad fall in the kitchen, horrible drug. I would wake up against a house wall not knowing how I got there.